Provider Demographics
NPI:1205226925
Name:WILSON, JESALYN DOVE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JESALYN
Middle Name:DOVE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:HARTMAN
Mailing Address - State:AR
Mailing Address - Zip Code:72840-9444
Mailing Address - Country:US
Mailing Address - Phone:479-746-1877
Mailing Address - Fax:
Practice Address - Street 1:1100 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4419
Practice Address - Country:US
Practice Address - Phone:479-754-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP-T1518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant